S 0256 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PT I NO. 0256
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL `V
IIUILDING PROJECT IDENTIFICATION
UILDING ADDRESS: SANITARY NO. APPLICAT ION SUBMITTAL DNO
/ I523 MEc I
O 'NAME: PHONE'. C OR'S NAME: LIC NO:
NIC CONTROL
',WARCHITECTIENGINFER: LIC NO: ES' ❑
FCOWA� PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
t ID
y affrm Nal I am licensedunderpraviainmof Chafer 9(commencing JOB DESCRI TION
OamXgm 3r one Hoarse.,and Prnres,n,nxealn.ai ainy lhcdae i, RESIDENTIALwo _y PERMIT ISSUANCEa1d of t. v,w2Z�7 ❑SFDWL ❑KITCHEN REMODEL.9ULic.N APPLIANCES-RESIDENTIAL ❑ADDITION UAIBING RIi-PIPE
I-GContractor
F y ARCHIT EC'I S DECLARATION PAYEES ❑MUI-H-UNIT STRUCTURAL.
Z O'er'Z I understand my plans shall be used as public records MODIFICATION
UP 10 ANI AMPS
O Z^ ❑INTERIOR ❑CHIMNEY REPAIR
P-It:M Licensed professional 201-1000AMPS IMPROVEMENT �SWIMMING POOLS
OWNER-BUILDER DECIARAI'[ON
g LLW 6 1 hereby aRrtn the 1 am exempt from the Conlracmr's License Law far the OVER IBfIB AMPS ❑BATH kEA10UliVREPAIR DEMOLITION
X 3�U following Tcason.(Suction 7031.5,Business and Profession.Codc:Any city m county SIGNS ELECTRICAL ❑OTHER
gi which q permit t constrict. Ite p demolish. pa y%f core
F.1 it tons L 4 theppl'c' if hp 11 M b d:nmment SPECIAL CIRCUIT/MISC.
��} that he licensedp n theprevisions fthcC i i L La (Chapter9
�gG�O farmmcnemgwthSxsuon]Omp of D'v,sioi3nfthaBus nes andimfex:r n'C:ulel ar TEMP.METER OR POLE INS'K COMMERCIAL:
d d C a, Nat he is exempt Nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X m_li Section 931.5 by any applicant lie o permit-subject thcapphramm a civil penaltynf POWER DEVICES
not more than five hundred dollars($SIXB.
El TENANT ❑FOODSERVICE
`Z Y IMPROVEMENT
�d
EJ 1,tax owner of the pmpeny.arniy employees with wage,.,Iheirsale comptroller. SWIMMING POOL ELECTRIC
�F.o will do the work,anddesweme,is not imondedoroRered fors.le(See 7] .Business / OTHER
s3 m and Pndesdnm Codc The Contractor:,License Law dues not apply to an owner of OUTLETS-SWITCHES-FlXTURES
pro,my who builds or improves thereon,and who dues such work himself or through
his awn employee,,provided that.such improvements are not intended or differed for NEW RESIDENTIAL ELEC rR SQ lel'.
sale.If.however.the building or improvement is sold within one year ofessmpletloo,the SQ.FT FLOOR AkE 5/SQ.PC
owner-builder will have the burden of proving Nm lie did not build or improve for par-
,me oLmlc.).
El I,us owner of the properly.am exclusively contracting with licensed common"m 'LAI'AL:
commit the Project(Sec.]814.Bu,inns and Professions Code:)The Contractors Li.
cense Law doe,not apply m an owner of property who builds or improves theme.and QTY. PLUMBING PERMIT FEE
whocontracts fmmchpmjec¢with acnntmcmrts)liccmwd phoaanun lWContmmors
License Law. PERMIT ISSUANCE
1vm exempt under See .B&P C forihia reason
Owner Date ALTER-DRAIN&VENT-WATER HiA) V�ALUATION
WORKER'S COMP17NSATION DECLARATION BACK FLOW PROTECT.DEVICE PAID 1 hereby affrm under penalty of Perjury one of the following declarations: A'1
i have.ad will maintain aCertilicate of Consent looll'.inwre for Worker's Compel DRAINS-FLOOR,ROOF,AREA.COND. STOHIES� TY PF.CONSTRUCTIOt
,anon,a,provided for by Section 379)of the IaMe Code,horde l e forannow of theIT
ark for which this permit is issued 'IXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 afthe labor Code.fortheper[nmmnce of the work Gr which this permit is issued, GAS-EA.SYS TEM.I INC.S OUTLETS pQp�
My War In cr and Policy �J�1�j ` Vf Eur MIN
C.rrienj 1 /�dJ Policy No'�� L� OAS-EA SYSTEM.OVIRJ(GA7 'V I1N
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This victim need nut hs,completed ifiM1e permit is bottom hundred dollam 61001
ter le".) GREASE')RAY PLSNCHF,CK PEE
I certify that in the performance ofthe work forwhichthis permit is issued,I shall SEWER-SANITARY-S'IORM IiA.200[IT
not employ any person in any manner so as m become subject the Workers'Comped- ENERGY FFP.
Zz sation Law,of California.Date WATER HEATER W/VFNT/ELECTR
Applicant i GRADING FEE
N NOTICE I'O APPLICANT:If,.for making this Ccnifc.te of Exemption,you mould WATHR SYSTEM?R17ATING
become subject to the Workers Compensation provisions of the Labor Codc,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a0
CONSTRUCTION LENDING leading
AGENCY NEW RESIDENTIAL,PUMP. SQ.FI'. PAID
UO kfarwhich Thi thatNorth there
issue (See 30lending agency for Performance of Date ReccipiN
(~ the wok for which this permit is issue)IScc.J(N],Civ.C.)
O U Imdur.,Name � TOTAL:
Isndcr s AJdress A .
1 certify the I have read this application and sem That the atxwe information is BUILDING FEF,
F' V) erred.I agree nr comply withall 'ty and county ordinate If,,and smlu laws miming m QTY. MECHANICAL PERMIT FEE
U building ennswction. Norize mpresentatt of this city to enter upon the SEISMIC FEE
ebnvcmentimal fere cion Pm ,sea PERMIT ISSUANCE
IWe)ngr m ed n nifyand eph ss the City of Cupertino against ELECTRIC FET:
liabilitiea,ju cats 1. expense. anyw'. .ac eagoinsis.id City AITERORADU'TOMECH
�
I'LUMBINGFEE �
' naq ¢e of a rod' gar Nrs
APPLIf U RS NO A I NO NT AIR HANDLING UNIT(TO 10.000 CI'M) MECHANICAL GEE
Stu EGL 1.11 5.
AIR HANDLING ONfi'(OVER 10.08)CFM) CONSTRUCTION TAX
ad/,m2553200?
"VCO r ;he EXHAUST HOOD(W/DUCT)
H '.AR OUS AT IAIS DISCLOSURE HOUSINGMITIGATION FEE
i mor ere goccupant store or handle hazardous material I I EATI NG UNIT(TO I WJXX)B Of
r., efiupertino ipal Code.Chapter 9.12,and the Health and Safety
cHEATING UNIT(OVER 100,0X)BTU)
El No PAID
VENTILATION FAN(SINGLE.k1iS1U1
Will the applicant or future building occupant use equipment or devices which Date Receipt M
toil ha'rnNoc, it eonm mmods as defned by the Bay Arun Air Quality Management BOILER-COMP(3HP OR tM,000 R'IU)
Ldmxnot
'[MAI.:
0N BOILER-COMP(OVER 100.0(10 BTU)
read the h.zufdous materialsreuiremcros under Chatter 6.95 of the Cal i- AIR CONDITIONER
q p ISSUANCE DATE
&t curretlyhaty Code.Section, ,thati 25533and25534.ImWesiand Natif Nc NEW'kES1UENTIAL AfIiCH. SQ.FT.not curmndy nave u teem,)hal it is my reomihiliiy m ramify iheacenpaments which mumbeoneed.,crit Time TOTAL: ISSUED BY: `
OFFICE